Initial vs subsequent

[inc1961]

When reading the CPT manual it states the "admitting" physician only can bill an initial inpatient code. Is this correct? Or did I interpret it incorrectly?

If a non admitting provider provides a consult can they bill an initial visit (Medicare patient, so consult codes are not billable to our MAC).

Is the patient considered new as an inpatient even if established in the office?

Thank you,

 

[Cavalier40]

No you read correctly. Only the admitting physician or hospitalist can bill the initial codes. My facility was billing those codes incorrectly before I got here, and we are under audit from 2 insurance companies partially because of incorrectly billing the initial e/m codes.

 

[inc1961]

Thank you,

 

[mitchellde]

That answer is not entirely correct. When Medicare made the decision to disallow the consultation codes they revised the manual for consultation billing and added a section for alternative consultation coding. They also created the modifier AI. The admitting provider with use the initial inpatient codes for the admit and is to attach the AI modifier to indicate that this is the admit. The consulting provider is to use the initial codes to indicate the consult as being the initial consult by that provider in the inpatient setting. So yes the consulting provider uses the initial codes for their first encounter as well. The initial codes are not restricted to the admitting provider. However if the admitting provider claim did not attach the AI modifier the claim for the consulting provider will deny.

 

[CMann12]

That answer is not entirely correct. When Medicare made the decision to disallow the consultation codes they revised the manual for consultation billing and added a section for alternative consultation coding. They also created the modifier AI. The admitting provider with use the initial inpatient codes for the admit and is to attach the AI modifier to indicate that this is the admit. The consulting provider is to use the initial codes to indicate the consult as being the initial consult by that provider in the inpatient setting. So yes the consulting provider uses the initial codes for their first encounter as well. The initial codes are not restricted to the admitting provider. However if the admitting provider claim did not attach the AI modifier the claim for the consulting provider will deny.

^ This is how I interpreted it too, but I've had a hard time verifying this. Do you happen to have a site or literature you could site for this? Much appreciated!

 

[daedolos]

Could this be why a consult on an emergency room visit is denied? I've recently run into a claim where the payer says that until the facility claim is processed, the professional claim will be considered unresolved.

Peace
@_*
It's not fair to the consulting practitioner.